Mark Barwick Reinsurance Large Commercial Programme Director, ACORD

Transcription

1 Mark Barwick Reinsurance Large Commercial Programme Director, ACORD 25 th January 2012

2 You Sir, are a Fraud! How to detect and prevent insurance fraud in insurance transactions David Hicks, KPMG Partner in Risk & Compliance, SME in counter fraud activities

3 USA The FBI estimate insurance fraud is more than $40 billion per year. Insurance Fraud costs the average U.S. family between $400 and $700 per year in increased premiums.

4 The UK 2012 survey found 60% of GPs reported a rise in patients attempting to make fraudulent claims for car accident injuries number of accidents has fallen every year since 2005, but cost of car insurance has risen by 20% in last two years. 70% rise in motor insurance injury claims in the past six years, despite a 23% drop in the number of casualties ABI estimates undetected general insurance claims fraud totals 1.9bn a year. ABI - detected pet insurance fraud soared to nearly 2m in 2011, from 420,000 in 2010

5 Fraud The questions What types of fraud are there? How does fraud differ across different product lines? What is the profile of a typical fraudster? How do you detect fraud, what techniques do you use? How do you prevent fraud? How does London market differ from general insurance? What is the estimated annual cost to the insurance industry of fraud to; a) general insurance b) London market? Is fraud cyclical with the economic cycle, i.e. worse in a recession?

6 David Hicks - KPMG

7 You sir, are a fraud! 25 January 2012

8 The information contained herein is of a general nature and is not intended to address the circumstances of any particular individual or entity. Although we endeavour to provide accurate and timely information, there can be no guarantee that such information is accurate as of the date it is received or that it will continue to be accurate in the future. No one should act on such information without appropriate professional advice after a thorough examination of the particular situation 8

9 Quiz famous fraudsters 9

10 Agenda How much does fraud cost? Current and emerging fraud types Profile of a fraudster What can you do to manage fraud? 10

11 How much does fraud cost? KPMG Fraud Barometer Fraud trends in the 2000s 1,600 1,400 Fraud Value m No. of Cases Reaching Court , Fraud Value ( m) 1, No. of Cases reaching Court Year Source: KPMG Fraud Barometer

12 How much does fraud cost? Rising Cost of Insurance Fraud Insurance Fraud Insurance Fraud ( billion) Source: (estimated) Year Association of British Insurers and National Fraud Authority 12

13 How much does fraud cost? Impact of the Recession on the Insurance Industry Changing Behaviour The economic climate could be creating a more lax attitude to fraud RSA research in March 2008 showed 3.6 million Brits think it s wrong to lie on an insurance claim In January 2009 they found that 4.7 million do not think making a fraudulent insurance claim is wrong Key Indicators An increase in very amateurish claims An increase in the proportion of suspect claims An increase in the proportion of claims referred to investigation that are proven to be fraudulent An increase in calls to the Insurance Fraud Bureau s (IFB) Cheatline An increase in walk-aways Impacts of Cuts Police resources are set to decline over the next few years and in particular resources dedicated to financial crime An erosion of middle management This necessitates a much greater need for the industry to be vigilant towards fraud going forward Recession Motivators Desperation and Lifestyle fraud Financial difficulties is naturally a key motivator Excessive pressure from within your organisation Source: Association on British Insurers 2009 Research Brief, RSA Research (2008, 2009) 13

14 Current and emerging fraud types Recent trends & findings Insurance fraudsters will not necessarily focus on misusing one insurance product they will often combine multiple fraud types for maximum benefit Public perception of opportunistic fraud is arguably apathetic false/exaggerated claims are a recompense for rising premiums Communication between law enforcement and industry needs improving Operational activity must not purely focus on insurance organised crime groups, but must also consider opportunistic individuals Due to the potential number of professionals involved in a claim, the insurance industry is vulnerable to corruption Know Your Customer (KYC) measures are not mandatory within General Insurance and the levels of control regarding payment methods vary between insurers leading to opportunities for ID or Payment fraud Source: Insurance Fraud Assessment City of London Police November

15 Current and emerging fraud types Common types of Insurance Fraud Non-disclosure fraud False claims Claims overstatement Duplicate claims Ghost brokers Supply-chain fraud Internal fraud 15

16 Profile of a fraudster External fraud: Example Organised Crime Groups (OCGs) are collaborating with a growing number of professional enablers including doctors, lawyers and vets who are all benefitting from advances in technology to widen their fraud operations One typical example is a Staged Accident, where two or more individuals deliberately crash their vehicles into each other, resulting in various claims. (Cash for Crash) Garage and Engineer Overcharge for vehicle parts Recovering Company Supplies damaged car for staged accident/provides invoice for recovered car Accident Management Company Helps stage accident Staged Car Accident Salvage Company Underpays insurer for scrap metal from cash Solicitor Represents victim False Victim Medical Treatment Service Provides treatment for nonexistent ailments Credit Hire Company Claims to provide victim with substitute car Collusive Doctor Supports alleged injury 16

17 Current and emerging fraud types Opportunities for internal and external fraud in the Insurance sales process Multiple opportunities for internal and external fraud Intermediaries Economic downturn Poor processes Complex IT environment Low quality controls Insurer Premium In Policy Sale Policy underwriting Policy Inception In-Flight Servicing and Management Claims, Benefits Calculation and Payment Claims Out Ongoing External Reporting Outsourcer Third party service providers Disgruntled employees Opaque Outsource agreements Poor training and supervision Poor business models Policyholder 17

18 Profile of a fraudster Internal Male 36 to 45 years old Holds a management position within the finance function or in a finance-related role Has been working for the same company for more than ten years Commits fraud against his own employer Operates in collaboration with other offenders Source: KPMG Report Who is a Fraudster June

19 Profile of a fraudster The Fraud Triangle: Internal fraud Opportunity 19

20 Profile of a fraudster Fraud triangle: Pressure Meet budgets/ expectations Debts Addiction drink, drugs Results at any cost Coercion or blackmail Family pressures I need the Money Illness 20

21 Profile of a fraudster Fraud triangle: Opportunity Poor controls/lack of monitoring Fraud can be hidden in complex transactions Exploiting errors Abuse of authority Lack of segregation of duties Lack of effective oversight/ resource 21

22 Profile of a fraudster Fraud triangle: Rationalisation Everyone else does it They do not pay me enough! Rules are made to be broken Who cares? I m the boss! It s only a small amount It s a victimless crime They can afford it I ll never get caught! It s a cost of doing business 22

23 Profile of a fraudster Warning signs Accounts manipulation / Fraudulent Financial Reporting Lack of trust / poor auditor relationships Dominance / lifestyle issues Undue secrecy Illegal unethical practices Significant director share sales High analyst or other pressures Declining industry / earnings High hope value Aggressive forecasts Highly-leveraged rewards Aggressive accounting policies Unique products unique risks Cash / funding gap Results exceed market trend High management turnover Profit warnings / credit warnings Complex corporate structures Related party arrangements Multiple banking arrangements Remote operations 23

24 Profile of a fraudster Warning signs Employee behaviour Lifestyle / Income mismatch Overextended personal finances Addictive behaviour Relationship issues Rarely takes holidays Refuses or does not seek promotion Resists or refuses new positions Poor motivation or unhappy Stressed, pressurised Unreliable, prone to mistakes, poor performance Shifts blame for errors, denies responsibility Overly secret Egotistic Bullies or intimidates colleagues Ability and performance not in tune with CV Has favourites or is surrounded by yes men / women Personal pay and reward could be manipulated Cannot produce notes / records of business meetings Vendors and suppliers will not speak to anyone but this person Cuts corners or bends the rules! 24

25 Profile of a fraudster Employee-Related Red Flags: 2010 and 2008 Percentage of red flags displayed by perpetrators of fraud according to according to members of the Association of Certified Fraud Examiners (ACFE) Behavioral red flag Living beyond means Financial difficulties Control issues, unwillingness to share duties Unusually close association with vendor/customer Wheeler-dealer attitude Divorce/family problems Irritability, suspiciousness or defensiveness Addiction problem Refusal to take vacations Past employment-related problems Complained about inadequate pay Excessive pressure from within organization Past legal problems Instability in life circumstances Excessive family/peer pressure for success Complained about lack of authority Source: Association of Certified Fraud Examiners (ACFE) Report to the Nations % 18.7% 22.1% 15.2% 19.2% 20.3% 17.6% 17.1% 14.1% 13.6% 11.9% 13.3% 10.2% 6.8% 9.3% 7.9% 7.9% 7.3% 7.5% 6.5% 6.3% 8.7% 5.6% 4.9% 5.1% 4.2% 4.6% 3.6% 38.6% 36.4% 34.1% 43.0% Percent of cases % 10.0% 20.0% 30.0% 40.0% 50.0% 25

26 What can you do to manage fraud? How do you prevent and detect fraud? Control Preventative / Detective Example Effective systems and controls Preventative Non disclosure of details Motor and personal details are put through the CUE system to check previous claims history Audit and Assurance Detective Audits of underwriting/claims function Segregation of duty Preventative Cheques are not returned to the claims handler Data analytics Detective Claims payments just below self-authorisation limit Payments made close to the expiry of a cover Training Preventative Regular training of fraud coordinators and front office staff Oversight and Governance Preventative and Detective Whistleblowing hotline Adequate reporting process in place Ongoing monitoring Detective Claims which are in a re-opened state at a particular point in time Claims fraud software Client onboarding Preventative Details captured at application stage to determine whether multiple attempts have been made to lower premium Information and intelligence sharing Preventative Sharing of information to wider industry e.g. names of individuals, suspect bank accounts etc. will assist in preventing further frauds and wider criminality 26

27 What can you do to manage fraud? Management s role in detecting fraud Occupational frauds are much more likely to be detected by whistleblowing than by any other means Whistleblowing 40.2% Management review Internal audit 13.9% 15.4% Percent of cases By accident 8.3% Detection Method Account reconciliation Document examination External audit 5.2% 4.6% 6.1% Surveillance/monitoring 2.6% Notified by police 1.8% Confession 1.0% IT controls 0.8% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0% Source: Association of Certified Fraud Examiners (ACFE) Report to the Nations

28 What can you do to manage fraud? The role of technology Technology is crucial in the identification and FNOL Data Analytics Suite Straight Through Specialist Claims Customer Outcome Claim Paid Claim Rejected Plays a key part in identification and monitoring of fraud at the First Notification of Loss; Can automate much of the filtering process between suspicious and valid claims Can be real time or backward looking on static data; Can look for common fraud patterns and scenarios; Anti Fraud Financial Crime MI Not the only solution must combine well with claims handlers, loss adjusters and investigators; Must be effectively calibrated to avoid false positives and negative regulatory/customer feedback; and Loss adjusters Field Investigators External Law Enforcement External Industry Database MI on claims stats must have integrity and reliability if to be used for reporting to external agencies and for KPI performance management; monitoring of fraud. 28

29 Future predictions 29

30 Questions? 30

31 Thank you DAVID HICKS Partner, Risk Consulting Financial Services Tel: +44 (0)

32 2012 KPMG LLP, a UK limited liability partnership, is a subsidiary of KPMG Europe LLP and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative, a Swiss entity. All rights reserved. The KPMG name, logo and cutting through complexity are registered trademarks or trademarks of KPMG International.

33 Next meeting: Thursday 23 rd February 2012 Any ideas for future sessions please

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